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Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis

Richard Hodin, MD
Massachusetts General Hospital


Crohn's disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract with a propensity to the distal ileum. It causes transmural inflammation of the intestines, which can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition. It occurs in about 200 cases per 100,000 and follows a bimodal distribution pattern with peaks in the 3rd and 6th decades of life. The exact cause of Crohn's disease is unknown, but is believed to be influenced by immune system disorders, genetics, and environmental factors. Diagnosis is usually made by endoscopy and clinical history. Endoscopic findings show characteristic skip lesions, and a cobblestone-like appearance is seen in approximately 40% of cases, representing areas of ulceration separated by narrow areas of healthy tissue. There is no cure for for Crohn's disease, and the goal of treatment is to palliate symptoms and includes both medical and surgical options. Medications such as antibiotics, aminosalicylates, corticosteroids, immunomodulators, and a variety of biologic medications are used to reduce inflammation and prevent recurrence, while surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications such as intestinal obstruction due to stricture, bleeding from ulcers, abscesses, and fistulas. Segmental intestinal resection of grossly evident disease followed by primary anastomosis is the usual procedure of choice. Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn's colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing, and thus a total abdominal colectomy with iliorectal anastomosis was performed. Laparoscopic access was gained, and the colon was mobilized and divided at the distal sigmoid colon. The colon was pulled through the infraumbilical port site and divided at the ileum, and a J-pouch was made. Anastomosis was achieved with an EEA stapler and confirmed with a scope, and the port sites were closed.

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